outcomes in thread lift for facial rejuvenation · minimally invasive surgical technique for facial...

ORIGINAL RESEARCH

Outcomes in Thread Lift for Facial Rejuvenation:a Study Performed with Happy LiftTM Revitalizing

Antonella Savoia • Ciro Accardo • Fulvio Vannini •

Basso Di Pasquale • Alfonso Baldi

To view enhanced content go to www.dermtherapy-open.comReceived: December 5, 2013 / Published online: January 17, 2014� The Author(s) 2014. This article is published with open access at Springerlink.com

ABSTRACT

Introduction: Barbed suture lifting is a

minimally invasive surgical technique for

facial rejuvenation. This study examined the

efficacy and associated risks with this

procedure, using a new synthetic,

monofilament suspension thread named

‘‘Happy LiftTM Revitalizing’’ (Promoitalia

International S.r.l, Naples, Italy).

Methods: All the patients had average aging

signs and required a lifting of modest degree. A

total of 37 thread lifts were performed over a

24-month period.

Results: In the majority of patients (89%), the

results obtained were considered satisfactory.

The incidence of complications was low. Only

6% of the patients had slight post-operation

asymmetry that was easily corrected. Minor

complications experienced by patients included

small ecchymosis (62%), mild erythema (40%),

small hemorrhage (25%), mild transitory

esthesia (6%) and mild post-operation

tumefaction (40%). Histopathological and

ecographic analyses were performed on the

treated skin of selected patients, demonstrating

that the lifting effect is guaranteed and fortified

by the cutaneous reaction that appears along the

length of the thread.

Conclusion: Thread lift with ‘‘Happy LiftTM

Revitalizing’’ is a safe procedure associated

with minor complications, when performed

on cohorts of patients requiring a facial lifting

of modest degree.

Keywords: Barbed sutures; Dermatology; Facial

ptosis; Facial rejuvenation; Happy LiftTM

Revitalizing; Thread lift

INTRODUCTION

As we age, the scaffolding dermal facial skin, as

well as the fat component, weakens. The

affected areas generally include the cheeks,

Electronic supplementary material The onlineversion of this article (doi:10.1007/s13555-014-0041-6)contains supplementary material, which is available toauthorized users.

A. Savoia � C. Accardo � F. Vannini � B. Di PasqualePromoitalia Group S.p.A., Pozzuoli, Naples, Italy

A. Baldi (&)Department of Environmental, Biological,Pharmaceutical Sciences and Technologies,Second University of Naples, Via L. Armanni 5,80138 Naples, Italye-mail: [email protected]

Dermatol Ther (Heidelb) (2014) 4:103–114

DOI 10.1007/s13555-014-0041-6

http://dx.doi.org/10.1007/s13555-014-0041-6

eyebrows, mandibular area and neck. This is

attributable to the fact that the connective

tissue of the skin becomes thinner and elastic

fibers undergo a collapse [1]. This

dermatocalasis of the facial and neck soft

tissues, including the superficial muscular

aponeurotic system (SMAS) and the muscular

tissue, is the cause of the distinctive aging signs

of the face [2]. Among other facial aging signs,

we can highlight the profile of the mandibular

margin, which is not clear anymore, displaying

its downfall (down aging of the jaw line); the

forehead has horizontal wrinkles at which other

vertical ones are added to the glabellar area; the

zygomatic malar region (middle face) displays a

downward sliding; the lachrymal furrow appears

and the naso-buccal and mandibular-bucco

deepens; the skin of the eyelid becomes flabby

and protrudes in correspondence to the lower

eyelid due to production of adipose bubbles;

and finally, plasmatic parcel and cutaneous

flabbiness disappear from the neck [3].

The facelift to correct facial aging has been,

so far, an elaborate and complicated procedure

that takes a long time to recover from [4]. The

recent introduction of absorbable barbed

sutures producing a lifting action for this type

of aging can be a good alternative to more

invasive procedures [5–13]. The plugs present

on the surface of the wires allow the

combination with other non-surgical

rejuvenation procedures, such as botulinum

toxin, which has a 6-month temporary effect,

or substances with a transient and volumizing

filler effect. Other non-surgical procedures

include radiofrequency that is limited to

treating only very superficial wrinkles and

mesotherapy, which deposits the so-called

useful chemicals just under the skin,

presumably increasing their usefulness in skin

rejuvenation and improvement of the tone [14].

The spines along the course of the wire act as a

hook to lift and support one area of the face

whilst relaxed. The plugs open like an umbrella

to form a support structure that lifts the sagging

skin [5, 7]. It is a soft approach that allows a safe

reduction of the signs of aging. Depending on

the material that makes up the suture and filling

threads, we distinguish them as non-absorbable

and absorbable threads [10].

In this study, we have analyzed a new type of

re-absorbable barbed suture, ‘‘The Happy LiftTM

Revitalizing’’ range. The aim of this study was to

evaluate the surgical outcomes associated with

this device in relation to eyebrow lifting,

forehead lifting, mid-face lifting (zygomatic

malar), upper-mandibular region lifting and

high cervical region lifting.

MATERIALS AND METHODS

Barbed Suture

The ‘‘Happy LiftTM Revitalizing range’’ is an

absorbable, monofilament, suspension thread

of synthetic origin (caprolactone) manufactured

by Assut Europe Spa for Promoitalia

International spa (Promoitalia International

S.r.l, Naples, Italy). This product belongs to

the category 07 of inactive implanted devices,

in the re-absorbable thread group, and in class

III of medical devices [15]. Moreover, the device

has the CE mark 0373 released by the Istituto

Superiore della Sanita dell’Italia (Italian Board

of Health, Rome, Italy).

This study has utilized only lifting threads.

In particular, Free floating for zygomatic and

mandibular area, Double needle for eyebrow

and neck area and Ancorage for mid-face lifting

(zygomatic malar) in patients over 60 years. In

detail, Double needle threads are convergent

bidirectional threads (length 12–23 cm, 2.0 usp

caliber) with straight needle (lengths 9 or

104 Dermatol Ther (Heidelb) (2014) 4:103–114

15 cm, 24G caliber) at the ends. Free floating

threads are convergent bidirectional threads

(length 12–23 cm, 2.0 usp caliber) which are

introduced into the hypoderm with the

assistance of cannula (Length 9/15 cm, 21G

caliber) and Ancorage are unidirectional,

barbed threads (Length 12.5 cm, 2.0 usp caliber).

Patients

Thirty-seven female patients, aged between 37

and 65 years old, participated in the study

between December 2010 and December 2012.

All procedures were performed in anti-aging

centers of Promoitalia (Promoitalia

International S.r.l, Naples, Italy). All patients

had average aging signs and required a lifting of

modest degree. The following cases have been

regarded suitable for lifting operations: marked

naso-labial fold; slightly defined mandibular

contour; general aspect of an aged face (eye

wrinkles, forehead wrinkles) and relaxed neck

and chin with skin-folds. The exclusion criteria

in the study were patients in whom aging signs,

such as facial lipoatrophy, evident laxity and

cutaneous hypotonicity, were more advanced

and evident and patients with an excessive

overabundance of skin, thus requiring a

removal. Patients who requested immediate

results, excessive lifting, traditional lifting, and

those with very advanced cutaneous-muscular

prolapse, pathologies to diagnose or with

diagnosed pathologies were also excluded.

Finally, for patients over 45, the recourse to

this method was considered valid only when

linked to ancillary techniques such as Phenol or

Trichloroacetic Acid (TCA) peeling, or laser

therapies (CO2, Radiofrequency), or autologous

fat transplant (in this case, it was necessary to

restore the sub-dermic volume). Based on the

different treatments, we divided the 37 patients

into three groups. Group 1 contained five

patients treated with Ancorage for mid-face

lifting. Group 2 contained eight patients

treated with Free floating for zygomatic and

mandibular area and Group 3 consisted of

twenty-four patients treated with Double

needle for eyebrow and neck area. No patient

modified his/her lifestyle and consent was given

to the protocol proposed. All patients

underwent a preventative checkup, including a

complete anamnesis, and had ultrasound and

photographic evaluation.

Compliance with Ethics

All procedures followed were in accordance

with the ethical standards of the responsible

committee on human experimentation

(institutional and national) and with the

Helsinki Declaration of 1975, as revised in 2000

and 2008. Informed consent was obtained from

all patients for being included in the study.

Treatment Protocol

The ‘‘Happy LiftTM Revitalizing range’’ was

inserted in hypodermic tissues of the face,

upper the SMAS, and in subcutaneous tissues

of the neck and forehead. Local anesthesia was

performed with 1–2% Lidocaine, diluted

Epinephrine (1/200,000 cc) and the addition of

diluted sodium hydrogen carbonate (NaHCO3)

(1/9 cc).

The Free Floating threads were introduced in

flabby tissues of zygomatic area with a cannula

needle (20/21G caliber 9 6 9 1, 2 mm 9 15,

24 cm) and subsequently, the cannula was

removed, leaving the thread in its place. The

thread, with bidirectional and convergent barbs

towards the center, was inserted inside the

needle carefully so that the barbs that had to

maintain their efficiency were not damaged.

The mechanical action exercised by the two

Dermatol Ther (Heidelb) (2014) 4:103–114 105

halves of the thread had to be symmetrical and

of the same entity; otherwise, the sliding of the

thread in the insertion level and the ‘‘exiting’’

from one of the access holes was possible. The

time necessary for the complete treatment

required was an average of 35–55 min.

The Double needle threads were utilized for

the treatment of the forehead, mandibular area

and the neck. The protocol used for the revival

of the eyebrow suggested the insertion of both

straight needles at a point located in

correspondence to the hairline. One proceeds

vertically downward until reaching the eyebrow

where both needles protrude. The course must

be tangential to the bone surface and within the

subcutaneous tissue. The median needle re-

enters in the same exit hole and traces the

eyebrow to exit the nasal edge. The needle

placed more laterally undergoes the same path,

symmetrically (Fig. 1a). The protocol used for

the redefinition of the mandibular contour

involves the use of a wire introduced through

a straight needle in correspondence to the

mandibular angle through two adjacent inlet

holes. The first needle goes along the ramus of

the lower jaw to the temporal region and the

second runs on the horizontal ramus of the

mandible for 4–5 cm (Fig. 1b). Finally, for the

treatment of the neck, a wire double needle is

introduced in correspondence to the

aponeurosis of platysma with both needles,

but in an alternating manner. It proceeds to

the region of the sternum cleido mastoid

drawing a ‘‘V’’ open towards the outside

(Fig. 1c).

The time necessary for a complete

treatment was, on average 20–40 min. The

threads may displace themselves from their

primal insertion position in the first 10 days

following traumas and therefore, loose the

‘‘gathering’’ established with the neighboring

tissues. Therefore, during the first 3 weeks

after the operation, patients were not

permitted to take part in any kind of intense

physical activity, to exercise any violent or

direct pressure on the areas in which the

threads were inserted or to perform vigorous

rubbing on the facial skin and neck.

Evaluation Protocol

Photographs of the treated areas taken from

different angles and with varying visualizations

(using the same positions of the subject, light

and the exposure of the shot) were taken after

25 days and at 2, 6 and 12 months after the

operation. Two facial shots have been used to

standardize the images and to try and obtain

useful iconographic documentation.

For the ultrasonic study of the skin and

subcutaneous tissue, MindrayTM DP 9900 Plus

(Mindray Medical International, Milan, Italy),

indicated for the bidirectional observation of

the connective tissue, was used to verify the

fibrosis induced by Happy LiftTM in fatty tissues

of the face and neck.

Fig. 1 a Double needle for the treatment of the eyebrow; b double needle for the redefinition of the mandibular contour;c double needle for the treatment of the neck


Histopathological analysis was performed on

two patients treated with Free Floating in the

zygomatic area. Bioptic drawings were carried

out on the left and right cheeks 60 days after the

operation, when a reduction in the entity of the

oscillating ptosis ranging between 100% and

75% was obtained. Excised tissue samples were

transferred in 4% (m/v) paraformaldehyde

solution and embedded in paraffin. Sections of

5 lm were stained with hematoxylin–eosin,

hematoxylin–van Gieson, and periodic acid-

Schiff (PAS)–Alcian blue hematoxylin.

Ultrasound evaluation was carried out 90 days

after the treatment to identify the structural

modifications to which the skin had been

subjected to, using B-mode ultrasonography.

The results were defined with a score derived

from the Global Aesthetic Improvement Scale

(GAIS), used as a reference parameter (Table 1).

The values in the scale were determined

independently by Fulvio Vannini and

Antonella Savoia and their concordance was

100%. A summary of the patients’

characteristics and the GAIS scores obtained

are provided in Table 2.

Statistical Analysis

Descriptive analysis was made using median

values and 95% Confidence Interval (CI). The

differences in the GAIS scores in the different

time-points of each group were performed using

the Wilcoxon’s test for nonparametric

dependent continuous variables. SPSS software

(version 17.00, SPSS, Chicago, USA) was used for

statistical analysis. A P (two tailed) value of

\0.05 was considered to indicate statistical

significance.

RESULTS

In 33 patients (89%), the result was considered

satisfactory, including 24 patients (65%) with

excellent results and 9 patients (24%) with a

good result. The result was considered

unsatisfying for the final four patients (11%).

This optimal cosmetic effect was statistically

significant not only immediately after the

treatment, but also after 6 months (P = 0.005).

Indeed, there was not a statistically significant

difference between the two evaluations.

None of the patients asked for the removal of

the threads immediately after the operation and

none of them encountered important

complications.

During the first 2 weeks, two patients from

Group 1 had slight post-operation asymmetry.

This was immediately corrected by slightly

compressing the surgeons’ right hand thumb

in the omo-lateral region of the hyper-corrected

Table 1 Global Aesthetic Improvement Scale (GAIS)

Degree Description

1 Exceptional improvement Excellent corrective result

2 Very improved patient Marked improvement of the appearance, but not completely optimal

3 Improved patient Improvement of the appearance, better compared with the initial

condition, but a touch-up is advised

4 Unaltered patient The appearance substantially remains the same compared with the

original condition

5 Worsened patient The appearance has worsened compared with the original condition


Table 2 Clinical characteristics of the patients, different treatments and Global Aesthetic Improvement Scale (GAIS)evaluation

Patient no. Age (years) Areas treated Threads type GAIS1 afterthe treatment

GAIS2 after6 months

1 52 Zygomatic area Free floating 2 1

2 54 Neck Double needle 3 2

3 63 Mid-face Ancorage 1 1

4 41 Mandibular contour Double needle 1 1






10 48 Eyebrow Double needle 2 1























face. The result after this exercise achieved the

patients’ complete satisfaction. In two patients

from Group 2 and three patients of Group 3, a

more severe asymmetry was corrected by

introducing one or two more threads in the

area of the hyper-corrected face. This operation

was performed about 30–45 days after the first

operation.

The most frequent minor complication was

the presence of small ecchymosis in 23 patients

(62%). The great majority of this ecchymosis

concerned the temporal area for the patients of

Group 1 and 2. Mild erythema was noticed in

15 patients (41%). These clinical signs were

protracted for a maximum of 3 weeks and did

not request any treatment. In nine patients

(24%), a small hemorrhage appeared

immediately after the introduction of the

thread in the sub-dermal layer of the skin. It

ceased either by mechanical compression or in

the moment during which the extremities were

cut off. Mild transitory esthesia of a maximum

of 2 months was encountered in two patients

(5%). Mild post-operation tumefaction was

observed in 15 patients (41%). These

tumefactions were successfully treated with

non-steroidal drugs. Table 3 summarizes all the

complications encountered and the different

treatments used. A patient treated for the

redefinition of the mandibular contour is

depicted in Fig. 2.

The thread was not visible because the

insertion area was sub-dermal and the thread

was transparent. All the blood, urine and

electrocardiogram tests were normal during

the testing period. The operation had minimal

or no side effects. All the participants were able

to return to their everyday activities 3 days after

the treatment.

Histopathological Analysis

The histological analysis was performed 2 and

6 months after the thread lift on two different

patients. In the first patient, 2 months after the

Table 3 Complications encountered and treatments used

Patientsgroup no.

Complication Solution

1 Asymmetry Slight compression

1–2 Asymmetry Introduce one or more

threads

1–2–3 Ecchymosis N/A

1–2–3 Erythema N/A

1–2–3 Small

hemorrhage

Mechanical

compression

1–2 Tumefaction Non-steroidal drugs

Table 2 continued

Patient no. Age (years) Areas treated Threads type GAIS1 afterthe treatment

GAIS2 after6 months








procedure, observation with an optical

microscope enabled the detection of a

fragment of thread in the subcutaneous tissue

to which a connective structure adhered. The

latter was structured around a roughly ovoid-

shaped cavity with a maximum diameter of

around 0.3 mm (Fig. 3a). The internal section of

this structure, looking into the cavity, was made

up of larger and rounder ‘‘fibroblastic’’ cells

surrounding a ‘‘Free floating’’ thread that

appears dark following the histological

preparations, but when fresh, was white. On

the other hand, on a fragment of skin taken

from the left cheek 60 days after the operation,

derma and epidermis with a normal aspect and

with a minuscule part of subcutaneous lacking

abnormal structures were seen. In this derma

adjacent to the insertion areas in the left upper-

mandible region of the Happy LiftTM

Revitalizing thread vessels and annexation

structures are normally represented and there

were no signs of inflammation (Fig. 3b).

Interestingly, in the biopsy performed after

2 months on the second patient, it is possible

to detect some connective structures in the

subcutaneous tissue, which form a ring with a

thickness of around 70 lm around a cavity

seat of the ‘‘Happy LiftTM Revitalizing’’. The

Fig. 2 Exemplificative case of facial rejuvenation. A patient treated for the redefinition of the mandibular contour. a Beforethe treatment. b Immediately after the treatment. c 6 months after the treatment

Fig. 3 a Fragment of skin removed 2 months after theprocedure from the right cheek containing a whitemicroscopic filament (Happy LiftTM Revitalizing). (H & E,original magnification 920). b Fragment of skin takenfrom the right cheek 60 days after the operation. Thedermis next to the areas of the right zygomatic malar, wherethe ‘‘Happy LiftTM Revitalizing’’ thread is inserted,normally represents annexation structures and vessels with

no signs of inflammation; an increase in the thickness ofthe papilla can also be noticed. (H & E, originalmagnification 910). c Fragment of subcutaneous tissueremoved 2 months after the procedure, showing a connectivestructure forming a ring with a thickness of around 70 lmaround a cavity seat of the ‘‘Happy LiftTM Revitalizing’’.(H & E, original magnification 920)


innermost part is made up of lager and rounder

fibroblastic cells crammed into 2–4 chains with

a higher number of dilated vessels. There were

also rare giant multinucleate cells with

histiocytic features (histiocytes) present. The

peripheral part of the connective structure

appeared to be made up of less young

connective tissue with a poor number of

dilated fibrohistiocytic and connective cells,

thickened with a small amount of vessels

(Fig. 3c). To note, we detected no signs of

acute inflammation, necrosis or other

significant pathological phenomenon in all

the specimens analyzed.

Ecotomographic Evaluations in B mode

This analysis confirms, through the hyper-

echogenicity due to the marginal fibrosis

around the threads, the persistence evidence

of the Happy Lift thread after 90 days from the

implant in zygomatic area. Indeed, fibrosis

promotes a natural repositioning of the tissues

and stimulates collagen regeneration with tissue

toning. The fibrotic process made is highlighted

as a hyper echoic area at two-dimensional

ultrasonography (Fig. 4a).

Moreover, it confirms that the specific spatial

geometry of the surface of the barbed thread is

responsible for the marginal fibrosis highlighted

in the ecographic image in B mode. In fact, it is

possible to observe in Fig. 4b, the particular

stereotaxic disposition of the threads route that

placed according to the standard map, is

arranged like a spoon course that embraces the

lowest point of the down aging of the jaw line.

DISCUSSION

Innovations in operative techniques generally

contribute to enhanced results, greater patient

happiness, and a decrease in operative

morbidity [1, 4]. The results of this study have

shown that the use of the ‘‘Happy LiftTM

Revitalizing’’ is a safe and successful technique

for facial rejuvenation. The immediate effect is

the lifting of the tissue, due to the mechanical

action produced by the thread, which contrasts

the falling of the area treated. This is possible

due to the arrangement of the threads’ barbs,

disposed in two directions (divergent and

opposite), compared to the middle point of

the thread. The reaction strength produced on

both its sides, in fact, allows the connection of

Fig. 4 Ultrasound evaluation of the treated zygomatic areaof two different patients 90 days from the date of theimplant. a The hyper-echogenicity due to the marginal

long-lasting fibrosis around the threads is evident; b Theparticular stereotaxic disposition of the threads route is tobe noticed


the tissue on each barb that functions as a hook

and at the same time, prevents the sliding and

movement of the thread in the two opposite

directions. Thanks to this specific geometry of

the ‘‘Happy LiftTM Revitalizing’’, anchorage

points are not required on the superior and

inferior part of the facial anatomic region to lift.

Once positioned in the subcutaneous tissue,

they will continue to practice their sustaining

action on the tissues. It is an advantage

compared to the unidirectional barbed threads

as these barbs are positioned in one direction.

Therefore, even if widespread, they lift the

tissue in only one direction [10, 13, 14]. The

histological valuations have highlighted that

the sub-dermal suspension thread used in this

study connects itself to the high and lateral

dermis retinacula cutis system, to the SMAS and

to the downward muscular bands to exercise an

effective anchoring and lifting action. In detail,

the histological modifications induced by the

thread ‘‘Happy LiftTM Revitalizing’’ can be

summarized in the following points. A

homogeneous fibrous capsule forms around

the thread that continues to assure the tissues’

traction and compactness. Fibrosis presents an

intensive new vascular genetic activity in its

context, with dilated vessels. The dermis

papillae appear to have a greater thickness

indicating the growth of the collagen

interstitial component. Finally, a significant

acute inflammatory response is not elicited by

the treatment. Therefore, it is possible to claim

that the lifting effect is guaranteed and fortified

by the cutaneous reaction (fibrosis) that appears

along the length of the thread, and that remains

effective and steady even when the thread is

completely re-absorbed (after about a year). The

re-absorption occurs due to the action of the

histiocitary reticule system, which concretises a

selective hydrolysis action of the re-absorbable

thread from the outskirts towards the center.

This is also confirmed by the data produced

with the ecographic analysis. It has to be

emphasized that the GAIS evaluation has not

been registered until 6 months after the

procedure. Therefore, it could be possible that

with a longer period of follow-up, some other

side effects could appear.

The most important limits of this technique

are that it is indicated for moderate cutaneous

falling. For overabundant tissue, the

prescription remains to be traditional lifting.

Nevertheless, it must be underlined that the

results encountered with different barber suture

lifting have shown a significant number of

adverse events and early recurrence [16, 17].

Therefore, the results of this study suggest that

increasing the number of patients treated with

the ‘‘Happy LiftTM Revitalizing’’ would confirm

the good results obtained in this study. Finally,

an important factor to be considered when

analyzing the results obtained with this

technique is the correct selection of the

patients to be treated. For these medical

devices, the most suitable candidates are those

with mild aging signs and that necessitate a

lifting of modest degree. In case of more

advanced and evident signs of aging, patients

must opt for traditional surgical options that are

more invasive and direct. Therefore, severe

selection criteria must be adopted when

selecting the patients to be treated with this

technique.

CONCLUSION

From our work, it appears that the sub-dermal

suspension with the re-absorbable thread

‘‘Happy LiftTM Revitalizing’’ constitutes an

efficient and safe procedure of mid-face lifting

and rejuvenation of the superior cervical region

of the face and neck. It is also possible to

associate other methods that allow the


optimizing of the complete facial rejuvenating

effect with botulin, fillers, chemical peelers,

photo-rejuvenation with a pulsed light, lip-

filling, etc. [1, 3]. The operation with such

threads does not require general anesthesia. It is

virtually without bleeding or pain, intra- and

post-operational and does not produce scars

that are visible on the skin nor does it require

post-operational recovery. The technique is

practicable in day surgery and the patient may

immediately return to everyday activities

shortly following the procedure [14].

ACKNOWLEDGMENTS

Dr. A. Baldi is the guarantor for this article, and

takes responsibility for the integrity of the work

as a whole. No funding or sponsorship was

received for this study or publication of this

article.

Conflict of interest. Alfonso Baldi is

scientific advisor of Promoitalia Group SpA.

A. Saviola, C. Accardo, F. Vannini and B. Di

Pasquale are employees of Promoitalia

International S.r.l, Naples, Italy.

Compliance with ethics guidelines. All

procedures followed were in accordance with

the ethical standards of the responsible

committee on human experimentation

(institutional and national) and with the

Helsinki Declaration of 1975, as revised in

2000 and 2008. Informed consent was

obtained from all patients for being included

in the study.

Open Access. This article is distributed

under the terms of the Creative Commons

Attribution Noncommercial License which

permits any noncommercial use, distribution,

and reproduction in any medium, provided the

original author(s) and the source are credited.

REFERENCES

1. Helfrich YR, Sachs DL, Voorhees JJ. Overview ofskin aging and photoaging. Dermatol Nurs.2008;20:177–83.

2. Mack WP. Complications in periocularrejuvenation. Facial Plast Surg Clin North Am.2010;18:435–56.

3. Nkengne A, Bertin C. Aging and facial changes–documenting clinical signs, part 1: clinical changesof the aging face. Skinmed. 2012;10:284–9.

4. Chaffoo RA. Complications in facelift surgery:avoidance and management. Facial Plast Surg ClinNorth Am. 2013;21:551–8.

5. Wu WTL. Barbed sutures in facial rejuvenation.Aesthet Surg J. 2004;24:582–7.

6. Lycka B, Bazan C, Poletti E, Treen B. The emergingtechnique of the antiptosis subdermal suspensionthread. Dermatol Surg. 2004;30:41–4.

7. LeeS, IsseN.Barbedpolypropylene sutures formidfaceelevation. Arch Facial Plast Surg. 2005;7:55–61.

8. Isse NG, Fodor PB. Elevating the midface withbarbed polypropylene sutures. Aesthet Surg J.2005;25:301–3.

9. Ruff G. Technique and uses for absorbable barbedsutures. Aesthet Surg J. 2006;26:620–8.

10. De Lorenzi CL. Barbed sutures, rationale andtechniques. Aesthet Surg J. 2006;26:223–9.

11. Sulamanidze MA, Fournier PF, Paikidze TG,Sulamanidze GM. Removal of facial soft tissueptosis with special threads. Dermatol Surg.2002;28:367–71.

12. Sulamanidze MA, Paikidze TG, Sulamanidze GM, NeigelJM. Facial lifting with ‘‘APTOS’’ threads: featherlift.Otolaryngol Clin North Am. 2005;38:1109–17.

13. Horne DF, Kaminer MS. Reduction of face and necklaxity with anchored, barbed polypropylene sutures(Contour Threads). Skin Therapy Lett. 2006;11:5–7.

14. Villa MT, White LE, Alam M, Yoo SS, Walton RL.Barbed sutures: a review of the literature. PlastReconstr Surg. 2008;121:102e–8e.


15. Council Directive 93/42/EEC of the EuropeanParliament and of the Council of 14 June 1993.http://www.ce-mark.com/MDD.pdf. Accessed 25Nov 2013.

16. Garvey PB, Ricciardelli EJ, Gampper T. Outcomes inthreadlift for facial rejuvenation. Ann Plast Surg.2009;62:482–5.

17. Rachel JD, Lack EB, Larson B. Incidence ofcomplications and early recurrence in 29 patientsafter facial rejuvenation with barbed suture lifting.Dermatol Surg. 2010;36:348–54.


http://www.ce-mark.com/MDD.pdf

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